VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Woods Edge
1401 North High Street
Franklin, VA 23851
(757) 562-3100

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Oct. 21, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced monitoring inspection conducted by two licensing inspectors from the Eastern Regional Office. The inspection was conducted on October 21, 2019 from 8:22 am until 7:35 pm. There were 56 residents in care.During the inspection a tour of the building was conducted. A medication observation was conducted in the assisted living and Asa's neighborhood (memory care unit). The breakfast meal was observed as well as a seated exercise activity in the memory care unit. Resident records and staff records were reviewed, to include criminal background checks for all new staff since the previous inspection. Emergency preparedness supplies and equipment were reviewed. Discussed buildings and grounds, snack times and availability, health care oversight dates as well as standards under admission, retention and discharge. Please remember to review documentation from outside agencies providing services to residents, to ensure documentation is detailed and accurate. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Measures to prevent re-occurrence and, 3. Person(s) responsible for implementing each step and/or monitoring any preventative action.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on record review and interview, the facility failed to ensure when hospice care is provided to a resident, the services provided were included on the individualized service plan (ISP). Evidence: 1. Resident #9's record indicated the resident is on hospice services. The hospice "Patient Information Report" dated 9-9-19 documented the resident would receive hospice services to include an aide, a registered nurse, a chaplain and visits from a MSW social worker once per month. The services detailed in the hospice report were not listed on the resident's ISP dated 10-08-19. 2. During interview, staff #1 acknowledged the resident was on hospice services and that the services provided by hospice were not included on the ISP.
Plan of Correction:	The Administrator will meet with care plan team to educate about breaking down the hospice services on the ISP for future reference. The care plan will be revised according to hospice benefits resident #9 receives and will be documented on the ISP.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure when a resident keeps their own medication in their room, the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. Evidence: 1. During resident #2?s record review with staff #2, the current UAI dated 03-26-2019 documented medications are administered by a lay person and documented the resident can ?Self-administer some medications.? The UAI also documented the resident ?May keep in apt. & self-administer Vicks Vaporub, Neosp. oint, Benadryl Cream, Monistat Cream, and prepH cream.? 2. During the tour of the facility with staff #2, a bottle of Cetirizine was observed in resident #2?s medicine cabinet, and a box of Dulcolax and Claritin were observed in the resident?s bathroom vanity drawer. The resident?s UAI did not document that the resident could self-administer the Cetirizine, Dulcolax, or Claritin. 3. During interview, staff #2 acknowledged that the resident was not permitted to keep the aforementioned medications in the room based on the UAI.
Plan of Correction:	Administrator will educate the review team to better monitor resident room checks especially on resident #2 room as she goes out of the facility frequently shopping. Resident #2 will also be re-educated that no over the counter medications are to be brought into the facility and self-administered unless with a doctor's order. Resident was already re-educated not to have OTC or Rx's medications in the apartment unless with a doctor's order and able to self-administer. Resident understands this policy regulation. New order obtained from physician for the Dulcolax tablets, Certrizine was already beingn administered daily and none had been taken from her medication bottle in the apartment. Resident states Zyrtec is not working so being discontinued. New order for Claritin and discontinued Zyrtec per physician order.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions. Evidence: 1. During the medication pass observation, staff #4 was observed crushing and administering resident #1?s medications, to include Aspirin EC 81mg. 2. During resident #1?s record review with staff #3, the physician?s order dated 09-12-2019 documented ?Aspirin EC 81mg DR- Take 1 tab every morning for chest pain- Do not crush.? In addition, the October 2019 Medication Administration Record also documented not to crush the Aspirin 81mg tablet. 3. During interview, staff #4 acknowledged resident #1?s Aspirin 81mg tablet was not administered to in accordance with the physician?s instructions.
Plan of Correction:	The plan of correction is that the Administrator will have the Director of Asa's Neighborhood educate staff #4 to pay closer attention to what medications are to be crushed and are not to be crushed during medication administration. Director of Asa's Neighborhood educated staff #4 the same day 10/21/19. Staff #4 knew not to crush, but accidentally crushed with her other medications. Medication error report was written up by the Director as part of education with family and physician aware.